Being in-network with Medicare comes down to one decision that many providers never realize they are making, which is whether to participate, stay non-participating, or opt out entirely. Enrollment gets you into the program, and this choice decides how Medicare pays you and what you can charge patients.
This post covers that choice, how it works, and how it connects to Medicare Advantage. For the application itself, including forms, PECOS, and timelines, use our companion guide on how to get credentialed with Medicare.
Key Takeaways
- Participating providers accept assignment on all Medicare claims and are paid the full fee schedule amount.
- Non-participating providers are paid 5% less and cannot charge patients above the 115% limiting charge.
- New providers choose a status with the CMS-460, and existing providers can change status during the mid-November through December 31 window.
- Opting out means no Medicare billing for two years and a signed private contract with every patient.
- Organizations cannot opt out. Only eligible individual practitioners can.
- Medicare Advantage plans credential and contract separately from Original Medicare.
What In-Network Means for Medicare
Medicare works differently from a commercial plan because it asks whether you accept assignment. Accepting assignment means you take Medicare’s allowed amount as payment in full and collect only the deductible, coinsurance, or copayment from the patient.
That is the heart of being in-network with Medicare. Participating providers agree to it for every covered service. Non-participating providers can decide claim by claim, with trade-offs that we cover below. Either way, you must first be enrolled, since neither status exists without a Medicare enrollment behind it. Our overview of medical credentialing shows where Medicare fits alongside commercial payers.
Participating vs. Non-Participating
CMS lays out the differences on its page for annual Medicare participation.
- Participating providers accept assignment on all claims and receive the full Physician Fee Schedule allowed amount, paid directly to them.
- Non-participating providers are paid 5% less than the fee schedule amount and may accept assignment case by case.
- Non-participating providers cannot charge patients above the limiting charge, which is 115%.
- Non-participating providers have limited appeal rights.
Participating providers also have their claim information forwarded to Medigap insurers, which makes life easier for patients with supplemental coverage. Whether the extra 5% outweighs the freedom to choose claim by claim depends on your payer mix, your patient population, and how much you rely on collecting patient balances.
When You Choose and How to Change
New providers submit the CMS-460 participation form with their enrollment application. CMS also says you have 90 days after your initial enrollment approval letter to decide, so do not let that window pass.
After that, you decide each year from mid-November through December 31 for the following year. If you are not participating and want to join, complete the CMS-460 and send a copy to your Medicare enrollment contractor. If you are participating and want to leave, send written notice to each MAC you bill, postmarked before December 31, with an effective date of January 1. If you are staying where you are, you do nothing.
Opting Out of Medicare
Opting out is a separate path from non-participation, and it is much more restrictive. An eligible practitioner signs an affidavit that is filed with every MAC that has jurisdiction over their claims. The opt-out lasts two years and renews automatically unless you cancel.
While you are opted out, you cannot bill Medicare for services to beneficiaries or receive Medicare payment for them, directly or through reassignment or Medicare Advantage. You must also sign a private contract with each beneficiary before you provide services, and you cannot opt out for some patients or some services but not others.
Several details matter before you commit.
- Eligible practitioners include physicians and several non-physician practitioners, such as nurse practitioners and physician assistants. Organizations cannot opt out.
- For a practitioner who is not enrolled or is non-participating, the affidavit is due within 10 days of the first private contract.
- You cannot sign private contracts for emergency or urgent care. Those services require Medicare enrollment to be reimbursed.
- To cancel, written notice must reach each MAC at least 30 days before the current two-year period ends.
Opting out suits a small number of cash-based practices. For most, it closes the door on a large share of patients, so talk it through with someone who knows your payer mix before you file.
Getting Enrolled First
Participation starts with enrollment. You need a valid license in good standing, a physical practice location where you see patients, and a National Provider Identifier. Medicare also screens for exclusions and sanctions, so any adverse action on your record can delay or block approval.
The forms, the PECOS steps, MAC response windows, revalidation, and change-reporting rules all live in our enrollment guide, so we do not repeat them here. Read that one first, then come back here to decide your status.
Medicare Advantage Is a Separate Track
Medicare Advantage plans are private insurance plans that deliver Medicare benefits. Each has its own network, its own credentialing, and its own contract, so being enrolled in Original Medicare does not put you in any of them. Enrollment is usually a prerequisite, but it is not the finish line.
Rates, prior authorization rules, and administrative requirements vary a lot between plans. That is where payer contracting and rate negotiations matter, because a Medicare Advantage contract is negotiated. Many plans use the same payers you already know, so see our guides to credentialing with Anthem, Aetna, Cigna, UnitedHealthcare, and Kaiser Permanente.
Common Participation Mistakes
- Letting the 90-day window after approval pass without choosing a status.
- Missing the December 31 deadline to change participation for the next year.
- Opting out without realizing that you cannot bill Medicare for any covered patient for two years.
- Assuming Original Medicare enrollment covers Medicare Advantage plans.
- Skipping the private contract before providing services under an opt-out.
Getting In-Network with Medicare FAQ
What does it mean to be in-network with Medicare?
Medicare does not run a traditional network. Being in-network usually means you are enrolled and accept assignment, which means you take Medicare’s allowed amount as payment in full and collect only the patient’s deductible, coinsurance, or copayment.
What is the difference between participating and non-participating Medicare providers?
Participating providers accept assignment on all claims and receive the full fee schedule amount. Non-participating providers are paid 5% less, may accept assignment case by case, and cannot charge patients above the 115% limiting charge.
When can I change my Medicare participation status?
New providers choose when they enroll, and CMS gives you 90 days after your initial approval letter to decide. After that, you can change status each year from mid-November through December 31 for the following year.
Can I opt out of Medicare?
Eligible individual practitioners can, by filing an affidavit with each MAC. The opt-out lasts two years and renews automatically. You cannot bill Medicare for beneficiaries during that time, and you must sign a private contract with each one first.
Can an organization opt out of Medicare?
No. CMS limits opt-out to eligible individual practitioners, including physicians and certain non-physician practitioners.
Do I have to be enrolled in Medicare before I can participate?
Yes. Participation is a status within your Medicare enrollment, so complete enrollment first. Our guide to getting credentialed with Medicare covers the forms and the PECOS application.
Does Medicare enrollment make me part of Medicare Advantage networks?
No. Medicare Advantage plans are private plans with their own networks, credentialing, and contracts, so you must apply to and contract with each plan separately.
Why should I get help with Medicare participation?
The choice affects your reimbursement and your patient mix, and the deadlines are strict. A credentialing and contracting partner can track the dates, file the forms, and compare Medicare Advantage offers.
Summary: Working Through Medicare Participation with Medwave
Medicare asks one question that matters long after enrollment, which is how you want to be paid and who you are willing to bill. Choose participating, non-participating, or opt-out deliberately, and mark the deadlines on your calendar.
Medwave handles billing, credentialing, and payer contracting for practices, including the Medicare Advantage contracts that follow Original Medicare. Our team can also review your medical billing setup so the status you choose shows up correctly on your claims. Contact us below to review your setup with our team.
Co-Founder and COO of Medwave, bringing more than 25 years of hands-on experience in healthcare revenue cycle management, payer contracting, and medical credentialing.